{"id":54231,"date":"2023-12-31T10:06:45","date_gmt":"2023-12-31T10:06:45","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=54231"},"modified":"2024-01-05T08:01:13","modified_gmt":"2024-01-05T08:01:13","slug":"influence-of-body-mass-index-on-the-markers-of-inflammation-and-oxidative-stress-among-young-females-during-menstrual-cycle","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no4\/influence-of-body-mass-index-on-the-markers-of-inflammation-and-oxidative-stress-among-young-females-during-menstrual-cycle\/","title":{"rendered":"Influence of Body Mass Index on the Markers of Inflammation and Oxidative Stress among Young Females during Menstrual Cycle"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

C-reactive protein (CRP) belongs to\nacute-phase reactants as its level increases during inflammation and infection.\nIt is primarily produced by liver cells, but also by endothelial and smooth\nmuscle cells of coronary arteries, macrophages, adipose tissues, and many other\ninflamed tissues throughout the body. Comparatively higher levels of CRP are\nobserved among females than males exhibiting gender variation, however, increases\nwith age in both genders. Increased CRP among healthy women is considered a\npredictor of cardiovascular events and myocardial infarction.1<\/sup> In women after menopause, the increased\nrisk of cardiovascular diseases is attributed to the low levels of endogenous\nestrogen. In women of the menstruating age group, although cardiovascular\nevents are rare, they correspond to the minimal estrogen level phase i.e. early\nfollicular phase. Estrogen is reported to be a regulator of inflammation since\nestrogen released in the blood exerts anti-inflammatory effects.1<\/sup> Several studies have shown that\nestrogen decreases the CRP while progesterone elevates it i.e., CRP level is\nnegatively associated with estrogen and positively with progesterone.1<\/sup>,<\/sup>2<\/sup>,<\/sup>3<\/sup><\/p>\n\n\n\n

Increased production of free\nradicals and reactive oxygen species (ROS), and insufficient antioxidant\ncapacity result in conditions of oxidative stress. Excessive ROS produced by\nsevere oxidative stress can damage DNA, and proteins, and cause other cell\ninjuries.4<\/sup> However, ROS produced by the\npreovulatory follicle is an important inducer of ovulation.5<\/sup> Obese people are reported to have\nhigher levels of oxidative stress than nonobese people, which could be due to a\nvariety of factors such as chronic inflammation, hyperglycemia, or antioxidant\ndefense system impairment.6<\/sup> Malondialdehyde\n(MDA) is a lipid peroxidation indicator, a final by-product of oxidative damage\nto cell membrane unsaturated fatty acids. It has been used as an effective\nbiomarker of lipid oxidation.7<\/sup><\/p>\n\n\n\n

To combat the oxidative stress induced\ndamages, the body has evolved several defense systems, including preventive and\nrepair processes, and an antioxidant system. Antioxidants are molecules that\ncan convert reactive molecules into relatively stable and inert substances.\nTotal antioxidant capacity (TAC) is the ability of serum to reduce generation and\nscavenge free radicals and reactive oxygen species. Studies suggest a\nreciprocal relationship between body fat content and antioxidant capacity.8<\/sup> Also, antioxidant status varies in\ndifferent phases of menstrual cycle.9<\/sup><\/p>\n\n\n\n

Iron is involved in important processes\nin the body, including growth and development, metabolism, and transport of\noxygen. Iron deficiency is the most common form of anemia, resulting in symptoms\nas shortness of breath, palpitations, reduced physical capacity, and decreased\nintestinal blood flow leading to malabsorption and motility disorders. One of\nthe common causes of iron-deficiency anemia is menstruation. Levels of iron in\nthe blood can vary over the different phases of the menstrual cycle.10<\/sup> Heavy menstrual blood loss can\ndeplete the body\u2019s iron stores.11<\/sup><\/p>\n\n\n\n

Globally 5-10% of young females are\naffected by hormonal-related reproductive problems like Polycystic ovary\nsyndrome (PCOS), more commonly seen among obese. Free radical-induced damages\nare now recognized as key events in the pathophysiology of many disorders\nincluding PCOS.12<\/sup> According to recent research, PCOS\npatients had considerably lower levels of serum TAC than normal women, which\ncould indicate higher oxidative stress.13<\/sup> <\/sup>Also, studies suggest that women\nwith PCOS have higher levels of inflammatory markers.14<\/sup> Understanding the mechanisms of increased\ngeneration of free radicals, ROS, and inflammatory biomarkers leading to the development\nof PCOS is important to plan strategies for prevention, early detection, and\ntherapy of PCOS. <\/p>\n\n\n\n

Rationale<\/strong><\/p>\n\n\n\n

Obesity\nincreases the incident risk for PCOS and some recent studies point out the connection\nof inflammation and oxidative stress in causing PCOS. A literature search\nrevealed scanty information in this regard among young females, therefore we\nintend to conduct this pilot study to explore more information and compare\nnormal and obese young participants. <\/p>\n\n\n\n

Objectives<\/strong><\/p>\n\n\n\n

To compare the levels of markers of inflammation, oxidative stress, total antioxidant capacity, and hemoglobin status among young females during different phases of the menstrual cycle.<\/p>\n\n\n\n

To observe if there is any difference in the measured parameters between normal and obese young females.<\/p>\n\n\n\n

Methods<\/strong><\/p>\n\n\n\n

Design of study<\/strong><\/p>\n\n\n\n

This pilot study was planned as a prospective,\nshort period of follow-up with no intervention. The cohort was followed during\nthe menstrual cycle from day 2 representing the early follicular phase (EFP) to\nday 21, representing the mid-luteal phase (MLP).<\/p>\n\n\n\n

Study\nPopulation<\/strong><\/p>\n\n\n\n

This study was conducted on female students at Gulf Medical University. The inclusion criteria were as follows: a) Females between the ages of 18 to 22; b) Belongs to either normal BMI category (range 18.5 – 24.9 Kg\/m2<\/sup>) or obese (\u2265 30 Kg\/m2<\/sup>). The exclusion criteria were as follows: using oral contraceptives; pregnancy; diagnosed with any chronic disease; sick in the previous two weeks; use of vitamins\/mineral supplements; and any form of smoking\/vaping                                     <\/p>\n\n\n\n

Sample\nSize<\/strong><\/p>\n\n\n\n

It was a pilot study conducted on a total of 37\nparticipants, 20 were with normal BMI, and 17 were obese.<\/p>\n\n\n\n

Study\nSettings<\/strong><\/p>\n\n\n\n

Gulf Medical University, Thumbay Medi-city, Ajman.<\/p>\n\n\n\n

Study Duration<\/strong><\/p>\n\n\n\n

It was a six-month-long study, conducted from\nJanuary to June 2023, including sample collection, lab investigations, data entry,\nanalysis, and report preparation.<\/p>\n\n\n\n

Ethical Issues<\/strong><\/p>\n\n\n\n

This\nresearch study got approval from the Institutional Review Board (IRB) of Gulf\nMedical University, ethical\napproval Ref.\nno. IRB\/COM\/STD\/44\/JULY-2022. Each\nparticipant provided the consent by signing the consent form. Throughout the\nstudy, access to the collected data was limited to the supervisor, ensuring\nutmost confidentiality. <\/p>\n\n\n\n

Study\nInstrument<\/strong><\/p>\n\n\n\n

Relevant information was collected from the study participants\nusing a validated instrument in the form of a questionnaire. It included\nquestions to collect basic information like age, marital status, length and\nregularity of cycles, the existence of any medical issues, medication or\nsupplement intake, smoking status, and to know if they had been sick recently. Subjects\nthat fit the inclusion criteria were selected based on this instrument.<\/p>\n\n\n\n

Methodology<\/strong><\/p>\n\n\n\n

Information\nrelated to the purpose and procedure of research along with the questionnaire link\nwas emailed to around 300 female students at Gulf Medical University. The responses\nallowed us to recruit subjects based on inclusion and exclusion criteria. After\nobtaining the signed consent, height and weight were measured and BMI was calculated\nfor each participant. Subjects not fitting any of the two BMI groups were\nexcluded and so achieved a total sample of 37 participants. The first day of\ntheir last menstrual period was recorded and each participant was followed\nindividually to collect blood samples on day 2 and day 21 of their menstrual\ncycle. On the respective days, temperature and blood pressure were measured,\nand blood samples were collected in two vials, one for hemoglobin, and the\nsecond to obtain serum for high-sensitivity CRP (hs-CRP), MDA, and TAC estimation.\nSerum samples were prepared immediately to prevent hemolysis. hs-CRP estimation\nwas outsourced and hemoglobin was estimated in Thumbay Labs as and when the\nsample was collected, with a maximum turnaround time of 4 hours. Serum samples\nfor the quantitative estimation of MDA and TAC were stored in four aliquots at\n-80\u00b0C. Once all samples were collected, MDA\nand TAC were measured as per the set protocol.<\/p>\n\n\n\n

Quantitative estimation of hs-CRP <\/strong><\/p>\n\n\n\n

hs-CRP test was used to\naccurately quantify the lower concentration range (0.5-10 mg\/L) and capture\neven the slightest fluctuation in the levels of CRP, utilizing the immunoturbidimetry\nmethod on a Beckman Coulter AU700. <\/p>\n\n\n\n

Quantitative estimation of MDA <\/strong><\/p>\n\n\n\n

A modified\ncolorimetric method using Thiobarbituric Acid Reactive Substances (TBARS) was\nused to estimate MDA levels.15<\/sup>,<\/sup>16<\/sup> Addition\nof 10 \u03bcL of  5% BHT per mL serum prevented\nfurther oxidation. Thiobarbituric acid (TBA) reacts with the MDA forming a\ncolored MDA-TBA adduct, quantified at the wavelength of 532 nm. The MDA standard\ncurve was prepared and used to calculate MDA concentrations in the serum\nsamples of our participants.  <\/p>\n\n\n\n

Estimation of TAC<\/strong><\/p>\n\n\n\n

A green chromophore\n(ABTS+<\/sup>) generated by the oxidation of 2,2\u2019-azino-bis(3-ethylbenzthiazoline-6-sulfonic\nacid (ABTS) in the presence of ferryl-myoglobin radical, absorbs at a wavelength\nof 640 nm. The presence of antioxidants in the serum sample inhibits the\ngeneration of ABTS+ <\/sup>radicals in an inverse relationship.17<\/sup> Serum\ntotal antioxidant capacity in the samples was reported as Trolox equivalent (TE),\nusing the Trolox Standard Curve. <\/p>\n\n\n\n

Estimation of Hemoglobin<\/strong><\/p>\n\n\n\n

Hemoglobin\nwas\nmeasured by sodium lauryl sulfate-methemoglobin method using the\nBeckman Coulter DxH 800\/900 automated analyzer.<\/p>\n\n\n\n

Statistical Analysis of Data<\/strong><\/p>\n\n\n\n

Using a paired sample T-test, parameters between day 2 and day 21 of the menstrual cycle were compared via Statistical Software SPSS (28.0.1.1). Mean values of parameters were compared between the normal and obese participants using an independent sample T-test. A P-value of \u02c20.05 was considered statistically significant.<\/p>\n\n\n\n

Results<\/strong><\/p>\n\n\n\n

Subject\nInformation<\/strong><\/p>\n\n\n\n

The questionnaire used to select the\nstudy population received responses from 60 students. A medical condition, such\nas asthma, diabetes, or allergy, was present in 15% of respondents, 6.7% were\nsmokers, and 6.6% were using nutritional supplements, hence were excluded. Subjects\nin the overweight BMI category (25 \u2013 29.9 Kg\/m2<\/sup>) were also excluded.\nSix subjects were afraid of needles and declined to give blood. Therefore, the\nfinal sample included 37 participants, with 20 falling into the normal BMI and\n17 into the obese category. <\/p>\n\n\n\n

Table 1 shows the data on BMI, age, and menstrual cycle length. Comparison of body temperature during EFP (Day 2) and MLP (Day 21) among each BMI group and between the normal and obese BMI categories shows no significant difference.<\/p>\n\n\n\n

Table 1: General characteristics of the sample population<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Group A (Normal BMI)<\/strong><\/p>\n<\/td>\n

\n

Group B (Obese BMI)<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Number of Participants<\/strong><\/p>\n<\/td>\n

\n

20<\/p>\n<\/td>\n

\n

17<\/p>\n<\/td>\n<\/tr>\n

\n

BMI (Mean\u2009\u00b1\u2009SD)<\/strong><\/p>\n<\/td>\n

\n

21.88 \u00b1 2.6<\/p>\n<\/td>\n

\n

33.14 \u00b1 2.4<\/p>\n<\/td>\n<\/tr>\n

\n

Age (Mean\u2009\u00b1\u2009SD)<\/strong><\/p>\n<\/td>\n

\n

20.3 \u00b1 1.59<\/p>\n<\/td>\n

\n

20.0 \u00b1 1.97<\/p>\n<\/td>\n<\/tr>\n

\n

Menstrual cycle (day)<\/strong><\/p>\n<\/td>\n

\n

28.75 \u00b1 3.76<\/p>\n<\/td>\n

\n

29.23 \u00b1 3.53<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

hs-CRP level as a biomarker of inflammation<\/strong><\/p>\n\n\n\n

Participants were distributed among the CVD risk groups based on hs-CRP levels, shown in Table 2.<\/p>\n\n\n\n

Table 2: Based on hs-CRP levels, participants distributed among the CVD risk groups <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

hs-CRP (mg\/L)<\/strong><\/p>\n<\/td>\n

\n

Normal Group<\/strong><\/p>\n<\/td>\n

\n

Obese Group<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

<1.0 mg\/L (Low Risk)<\/strong><\/p>\n<\/td>\n

\n

50%<\/p>\n<\/td>\n

\n

60%<\/p>\n<\/td>\n

\n

23.5%<\/p>\n<\/td>\n

\n

17.6%<\/p>\n<\/td>\n<\/tr>\n

\n

1\u20133 mg\/L (Average Risk)<\/strong><\/p>\n<\/td>\n

\n

30%<\/p>\n<\/td>\n

\n

20%<\/p>\n<\/td>\n

\n

47.1%<\/p>\n<\/td>\n

\n

47.1%<\/p>\n<\/td>\n<\/tr>\n

\n

>3.0 mg\/L (High risk)<\/strong><\/p>\n<\/td>\n

\n

20%<\/p>\n<\/td>\n

\n

20%<\/p>\n<\/td>\n

\n

29.4%<\/p>\n<\/td>\n

\n

35.3%<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Table 3 show the comparison of mean hs-CRP levels between the EFP (day 2) and MLP (day 21) of the menstrual cycle among the normal and obese participants. A significantly higher level was seen among obese subjects compared to normal BMI on each of the observed days. Also, significantly higher levels of hs-CRP on day 2 among normal BMI, and on day 21 among obese BMI was observed.<\/p>\n\n\n\n

Table 3: Comparison of serum hs-CRP levels on Day 2 and Day 21 of menstrual cycle across BMI Groups <\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Serum hs-CRP (mg\/L)<\/strong><\/p>\n<\/td>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Group A<\/strong><\/p>\n

(Normal BMI)<\/strong><\/p>\n<\/td>\n

\n

1.63 \u00b1  1.57<\/p>\n<\/td>\n

\n

1.37 \u00b1 1.54<\/p>\n<\/td>\n

\n

\u02c20.001<\/p>\n<\/td>\n<\/tr>\n

\n

Group B<\/strong><\/p>\n

(Obese BMI)<\/strong><\/p>\n<\/td>\n

\n

2.96 \u00b1 2.77<\/p>\n<\/td>\n

\n

3.21 \u00b1 2.72<\/p>\n<\/td>\n

\n

\u02c20.001<\/p>\n<\/td>\n<\/tr>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n

\n

0.011<\/p>\n<\/td>\n

\n

0.012<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

The correlation coefficient of BMI to serum hs-CRP levels on\nday 2 and day 21 was 0.417 and 0.482 respectively, indicateing a moderate\npositive association.<\/p>\n\n\n\n

Malondialdehyde\nlevel as a biomarker for oxidative stress<\/strong><\/p>\n\n\n\n

Table 4 show a significant difference in serum MDA values, with the level being significantly higher on day 21 compared to day 2 and higher among obese compared to the normal BMI group. <\/p>\n\n\n\n

Table 4: Comparison of serum MDA levels on Day 2 and Day 21 of menstrual cycle across BMI Groups<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Serum MDA (\u00b5M\/L)<\/strong><\/p>\n<\/td>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Group A<\/strong><\/p>\n

(Normal BMI)<\/strong><\/p>\n<\/td>\n

\n

3.581 \u00b1 1.66<\/p>\n<\/td>\n

\n

4.9 \u00b1 2.15<\/p>\n<\/td>\n

\n

0.02<\/p>\n<\/td>\n<\/tr>\n

\n

Group B<\/strong><\/p>\n

(Obese BMI)<\/strong><\/p>\n<\/td>\n

\n

4.79 \u00b1 1.33<\/p>\n<\/td>\n

\n

6.49 \u00b1 2.37<\/p>\n<\/td>\n

\n

<0.001<\/p>\n<\/td>\n<\/tr>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n

\n

0.01<\/p>\n<\/td>\n

\n

0.04<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Based on the correlation coefficient\nbetween serum MDA and BMI, a moderate positive correlation was seen on day 2\n(0.340) and a weak positive on day 21 (0.252).<\/p>\n\n\n\n

TAC as a\nmarker for the antioxidant activity<\/strong><\/p>\n\n\n\n

Table 5 show a significant difference in serum TAC values on Day 2 between the normal and obese subjects, with normal BMI having higher TAC. Also, among the normal BMI group, TAC was significantly higher on day 2 compared to day 21.<\/p>\n\n\n\n

Table 5: Comparison of serum Total Antioxidant Capacity (TAC)  on Day 2 and Day 21 of menstrual cycle across BMI Groups<\/strong>.<\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Serum TAC (TE\/L)<\/strong><\/p>\n<\/td>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Group A<\/strong><\/p>\n

(Normal BMI)<\/strong><\/p>\n<\/td>\n

\n

323.67 \u00b1 47.88<\/p>\n<\/td>\n

\n

314.5 \u00b1 70.51<\/p>\n<\/td>\n

\n

0.058<\/p>\n<\/td>\n<\/tr>\n

\n

Group B<\/strong><\/p>\n

(Obese BMI)<\/strong><\/p>\n<\/td>\n

\n

310.98 \u00b1 100.12<\/p>\n<\/td>\n

\n

281.96 \u00b1 107.64<\/p>\n<\/td>\n

\n

0.962<\/p>\n<\/td>\n<\/tr>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n

\n

0.032<\/p>\n<\/td>\n

\n

0.392<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Based on the correlation coefficient\nof serum TAC on day 2 (-0.174) and day 21 (-0.147), there is a weak negative\nassociation between BMI and TAC suggesting an inverse relationship.<\/p>\n\n\n\n

Hemoglobin\nas a marker of anemia<\/strong><\/p>\n\n\n\n

Table 6 show a significant difference in the hemoglobin levels between day 2 and day 21 of the menstrual cycle among each group based on BMI. However, no significant difference can be seen between normal and obese groups on either of the days. The levels of hemoglobin increase from day 2 to day 21 in the normal category, while there is a dip in the level among the obese group.<\/p>\n\n\n\n

Table 6: Comparison of Blood Hemoglobin on Day 2 and Day 21 of menstrual cycle across BMI Groups<\/strong><\/p>\n\n\n\n\n\n\n\n\n\n
\n

 <\/p>\n<\/td>\n

\n

Blood Hemoglobin (g\/dL)<\/strong><\/p>\n<\/td>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Day 2<\/strong><\/p>\n<\/td>\n

\n

Day 21<\/strong><\/p>\n<\/td>\n<\/tr>\n

\n

Group A<\/strong><\/p>\n

(Normal BMI)<\/strong><\/p>\n<\/td>\n

\n

12.12 \u00b1  1.33<\/p>\n<\/td>\n

\n

12.28 \u00b1 1.54<\/p>\n<\/td>\n

\n

\u02c20.001<\/p>\n<\/td>\n<\/tr>\n

\n

Group B<\/strong><\/p>\n

(Obese BMI)<\/strong><\/p>\n<\/td>\n

\n

12.06 \u00b1 1.73<\/p>\n<\/td>\n

\n

11.97 \u00b1 1.72<\/p>\n<\/td>\n

\n

\u02c20.001<\/p>\n<\/td>\n<\/tr>\n

\n

P-Value<\/strong><\/p>\n<\/td>\n

\n

0.247<\/p>\n<\/td>\n

\n

0.397<\/p>\n<\/td>\n

\n

 <\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n\n\n

Based on the correlation coefficient of BMI to the levels of\nhemoglobin on days 2 (-0.103) and 21 (-0.164), a weak negative correlation can\nbe seen.<\/p>\n\n\n\n

Table 7 summarizes the findings of hs-CRP, MDA, TAC, and hemoglobin, comparing between day 2 and day 21 of each group and also comparing between the two groups i.e. normal and obese. <\/p>\n\n\n\n\n\n
\"\"<\/td>\n\n

Table 7:<\/strong> Comparison of laboratory parameters on Day 2 and Day 21 of menstrual cycle among Normal BMI category, obese BMI category, and between the two groups of the population<\/strong><\/p>\n

<\/p>\n

Click here to view Table<\/a><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n\n\n

Discussion <\/strong><\/p>\n\n\n\n

In this study, levels of hs-CRP,\noxidative damage, total antioxidant capacity, and hemoglobin were assessed and\ncompared between the phases of the menstrual cycle among young females with normal\nand obese BMI groups. <\/p>\n\n\n\n

Inflammation<\/strong><\/p>\n\n\n\n

Results generated for the\ninflammation marker showed a significant difference in serum hs-CRP values on\nday 2 and day 21 of the menstrual cycle among the normal and obese groups\n(Table 3). Among the obese category, hs-CRP levels were comparatively elevated than\nthe normal BMI. Excess adipose tissue in obese induces chronic low-grade\ninflammation by secreting proinflammatory adipocytokines like TNF-\u03b1, IL-1, and IL-6\nand reducing the level of adiponectin, an anti-inflammatory adipokine.18<\/sup>,<\/sup>19<\/sup> Increased levels of hs-CRP\nsynthesized in response to increased expression of adipocytokines have an\nimportant role in the atherogenic process in obese people who are more susceptible\nto cardiovascular diseases.18<\/sup>,<\/sup>19<\/sup> Moreover, several studies reported\na rise of inflammatory markers including hs-CRP among women with PCOS, more\noften seen in obese females compared to normal BMI.20<\/sup>,<\/sup>21<\/sup> hs-CRP level of more than 1.0 mg\/L in\napproximately 82.5% of our obese participants (Table 2), indicates high chances\nof developing cardiovascular disorders and PCOS.<\/p>\n\n\n\n

Comparing the inflammation marker between\nthe phases of the menstrual cycle, our results showed higher levels of hs-CRP\nduring the EFP compared to MLP in the normal BMI category (Table 3), which is supported\nby several studies. Vashishta et al<\/em> studied regularly menstruating\nfemales with a mean BMI of 23 \u00b1 3.81 and showed follicular phase had significantly\nraised CRP level than the luteal phase.22<\/sup> Another study conducted by Gursoy\net al<\/em> on a sample with a mean BMI of 23.2 \u00b1 3.6 also reported CRP levels in\nEFP being significantly higher than the luteal phase.2<\/sup> Another study conducted by Wander\net al<\/em> on non-obese females also showed high CRP during menses,\nthe estrogen level being negatively\nassociated with CRP, while progesterone demonstrated a positive association.3<\/sup> However, contrasting these findings,\na study by Saxena\net al<\/em> on twenty healthy females demonstrated CRP levels do not vary\nsignificantly between the early follicular and early luteal phases.23<\/sup> Blum et al<\/em> showed normal-weight females having\nhigher CRP in the luteal phase compared to the overweight group.24<\/sup> Among the obese, our results show higher levels of hs-CRP during\nthe MLP compared to EFP. An extensive literature search did not reveal any\nstudy comparing the hs-CRP among obese young females during the EFP and MLP.\nTherefore, any support for this result is currently not available. The variation in\nthe results in different studies can be attributed to the day of sample\ncollection as the hormonal variation during the cycle influences the level of\nCRP, during menses both estrogen and progesterone are low, estrogen peaks during\nlate follicular, and progesterone increases during luteal phase along with a\nsecond surge of estrogen.1<\/sup> <\/p>\n\n\n\n

Oxidative stress<\/strong><\/p>\n\n\n\n

Our study indicates obese females experience\nhigher levels of OS compared to normal BMI (Table 4). Elevated levels of serum\nMDA among the obese population,25<\/sup> and specifically among obese\nfemales compared to the normal BMI groups, are reported by other studies also.26<\/sup> Visceral fat accumulation promotes a\npro-oxidant and proinflammatory environment, significantly contributing to\nobesity-associated diseases.6<\/sup> Obesity-induced chronic low-grade\ninflammation, mediated by TNF-\u03b1, IL-1, and IL-6, increases the production of ROS\nthrough the activation of several biochemical pathways including mitochondria\nand NADPH oxidase systems.6<\/sup> <\/p>\n\n\n\n

Our research findings also suggest\nthat levels of MDA in the blood are higher during the MLP compared to the EFP\n(Table 4). Similar results were demonstrated in other studies that investigated\nthe reactive oxygen metabolites throughout the menstrual cycle and discovered\nthey start increasing from day 6, peak at day 15, and then start declining to\nreach a minimum level on day 2.27<\/sup> Another study reported significantly\nlower levels of hydrogen peroxide and thiobarbituric acid reactive substances\nas markers of OS in urine during the follicular stage when compared to the\nluteal segment of the cycle.28<\/sup> The peak OS during the central\nphase of the cycle i.e. period of ovular maturation and possible implantation, corresponds\nto the estrogen and lieutining hormone peaks, while the progesterone peak seems\nto correspond with an OS recovery phase.27<\/sup> The increased cellular activity for\nthe increased energy production during the ovulatory phase subsequently\nincreases the production of free radicals and reactive oxygen metabolites.27<\/sup> It has been observed that oxidative\nstress affects women for approximately two-thirds of the menstrual cycle.27<\/sup> The role of ROS produced by the\npreovulatory follicle in inducing ovulation is also reported, and inhibition of\nROS has been found to disrupt the ovulation process.5<\/sup> This indicates a significant role of\nOS in the physiological events of the menstrual cycle. However, it is important\nto note that the absence of significant differences in oxidative stress markers\nduring different phases of the menstrual cycle is also reported.29<\/sup><\/p>\n\n\n\n

Total Antioxidant Capacity <\/strong><\/p>\n\n\n\n

Discussing the biological variation\nof antioxidant status with the menstrual cycle, our results show a weak negative\ncorrelation between TAC and BMI. These findings correspond to Chaves et al<\/em>.,\nwho reported decreased TAC among obese compared to normal subjects.30<\/sup> Singh et al.<\/em> further\nexplained obesity can result in a reduction in antioxidants due to an increase\nin ROS production.31<\/sup> To understand the effects of\nobesity in otherwise healthy females, Chrysohoou et al. <\/em>conducted the\nATTICA study in Greece and discovered that obese or overweight females have 10%\nless serum TAC than normal-weight females.8<\/sup> <\/sup><\/p>\n\n\n\n

Several studies report an increase\nin serum TAC from the late follicular phase to the early luteal phase.9<\/sup>,<\/sup>32<\/sup> According to Michos et al.,<\/em>\ntotal antioxidant status is maximum during the ovulation time which corresponds\nto estrogen peak and then starts declining.33<\/sup> In our study we did not collect the\nsample during the ovulation time, hence did not get the peak value, and the\ndifferences in TAC during the EFP and MLP turned out to be non-significant\n(Table 5).<\/p>\n\n\n\n

The young obese females in our study\nhave significantly higher hs-CRP, lower TAC, and higher OS compared to normal\nhealthy females. Similar findings are reported among young obese PCOS  patients, thus warranting clinical evaluation\nwith prevention strategies for our study participants.34<\/sup><\/p>\n\n\n\n

Hemoglobin <\/strong><\/p>\n\n\n\n

Regarding hemoglobin, the findings\nin this study show lower levels in the EFP compared to the MLP in the normal\nBMI category (Table 6). This is in agreement with the patterns seen by Chandra et al,<\/em>35<\/sup> and Shilpa et al.<\/em>36<\/sup> Blood loss during menstruation\ncauses a deficit in iron stores and may contribute to iron deficiency. The\nincreased hemoglobin concentrations in the luteal phase may be due to enhanced\nerythropoiesis to make up for the blood loss during menstruation.36<\/sup><\/p>\n\n\n\n

In the obese category, hemoglobin was higher in the EFP than\nin the MLP (Table 6). Similar results were reported in another study,\nexplaining increased adipocytes to be a source of circulating estrogens and the\nvariations in the levels of estrogen and progesterone influence the plasma\nvolume. Fluid retention due to the presence of estrogen during the luteal phase\ncauses hemodilution, reducing hemoglobin levels.37<\/sup>,<\/sup>38<\/sup> <\/sup>However, loss of blood during regular menstruation\ndoes not significantly impact the hemoglobin level thus maintaining oxygen-carrying\ncapacity.38<\/sup><\/sup><\/p>\n\n\n\n

Our study also reports higher mean levels\nof hemoglobin in the normal BMI compared to the obese category during both\nfollicular and luteal phases, though not proven to be statistically significant\n(Table 6). The negative correlation between BMI and hemoglobin among young\nfemale university students is also reported by Ahad et al.,<\/em>39<\/sup> <\/sup>and Acharya et al.<\/em>40<\/sup> Study by Cepeda-Lopez et al. <\/em>indicatedinflammation related to adiposity\ndecreases iron absorption irrespective of the body iron store status.41<\/sup> Hepcidin\nhormone found in the liver is reported to be a negative regulator of iron level.42<\/sup>\nAmong the obese, elevated levels of proinflammatory cytokines may increase the generation of hepcidin by the hepatocytes and adipocytes. Elevated hepcidin inhibits the gene for\nferroportin, a protein involved in transporting iron from inside the cells to outside, reaching the blood. High hepcidin also decreases iron absorption from the intestine and increases the traping of iron in macrophages and the reticuloendothelial system.42<\/sup>\nIn addition, inflammation upregulates the formation of an iron-binding protein,\nlipocalin-2, causing iron sequestration in the adipocytes.43<\/sup>\nThus, adiposity-induced low-grade inflammatory state can be an explanation for\nslightly lower mean hemoglobin observed in obese females compared to normal BMI\nin our study. <\/strong><\/p>\n\n\n\n

Limitations<\/strong><\/p>\n\n\n\n

It was a pilot study, hence the\nsample size was small. We chose only one marker to assess the inflammation,\noxidative stress, antioxidant, and iron status. Also, the cyclical variation of\nfemale reproductive hormones influences all these parameters. Hence, a larger\nstudy monitoring more parameters related to inflammation, oxidative stress,\nantioxidant status, and iron status, including reproductive hormone levels,\nassessing at several points during the menstrual cycle will help clearly\nunderstand the physiological variations and the influence of BMI.<\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

According to the results of our study, significant differences were observed in the concentrations of MDA, TAC, hs-CRP, and hemoglobin during EFP and MLP of the menstrual cycle among normal and obese young females. An increase in levels of hs-CRP, a biomarker of inflammation, and MDA as a biomarker of oxidative damage, and a reduction in total antioxidant capacity were noticed among the obese category compared to the normal BMI during both MLP and EFP of the menstrual cycle. As increased inflammation and oxidative stress are also observed in PCOS, it warrants clinical evaluation with prevention strategies for our study participants. Also, the results of this study could serve as a starting point for further elaborate research including biological parameters connected to oxidative stress and inflammation unraveling the etiology of hormonal disorders like PCOS in women. <\/p>\n\n\n\n

Acknowledgments<\/strong><\/p>\n\n\n\n

We appreciate the guidance of Dr. Anusha Sreejith, Assistant Professor in Demography, Department of Community Medicine, Gulf Medical University, in conducting statistical analysis. <\/p>\n\n\n\n

Conflict of Interest<\/strong><\/p>\n\n\n\n

The authors declared no conflicts of interest. This research was entirely supported by Thumbay Labs and Gulf Medical University, Ajman, UAE.<\/p>\n\n\n\n

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